Provider Demographics
NPI:1942277843
Name:EJIOFOR, MOSES C SR (MD)
Entity Type:Individual
Prefix:
First Name:MOSES
Middle Name:C
Last Name:EJIOFOR
Suffix:SR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1515 KANIS PARK DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-4569
Mailing Address - Country:US
Mailing Address - Phone:501-603-9277
Mailing Address - Fax:501-603-9877
Practice Address - Street 1:1515 KANIS PARK DR
Practice Address - Street 2:SUITE B
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-4569
Practice Address - Country:US
Practice Address - Phone:501-603-9277
Practice Address - Fax:501-603-9877
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2021-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-1071207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR131530001Medicaid
AR5K465Medicare PIN
ARG14667Medicare UPIN